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During a community health screening fair for older adults, the nurse observes a client who has pale, bluish feet, with sores on both lower extremities that are healing poorly. Which intervention should the nurse implement?
- A. Refer to healthcare provider for complete evaluation.
- B. Send client to the emergency department for treatment.
- C. Instruct client to apply antibiotic ointment to sores.
- D. Create a list of foods that promote wound healing.
Correct Answer: A
Rationale: Pale, bluish feet with poor-healing sores suggest serious conditions like peripheral vascular disease, requiring a comprehensive healthcare provider evaluation.
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A prescription for discharge is written for an elderly client who has asked to be discharged to home. The client lives alone and is able to walk 10 to 15 feet (3 to 4.5 meters) with assistance. Which action should the nurse implement first?
- A. Review the home medication schedule with the client and family.
- B. Provide the client with information about medical alert devices.
- C. Arrange for a bedside commode to be delivered to the home.
- D. Meet with the case manager to plan a home safety evaluation.
Correct Answer: D
Rationale: A home safety evaluation is critical to identify hazards and ensure the client's limited mobility is accommodated, preventing falls and ensuring safety.
A school nurse is developing a health risk screening protocol for use at an elementary school. Which information is most important for the nurse to include in this protocol?
- A. Long bone density testing.
- B. Annual flu vaccination status.
- C. Weight and height measurement.
- D. Serum total cholesterol level.
Correct Answer: C
Rationale: Weight and height measurements are essential for assessing growth, detecting malnutrition or obesity, and monitoring overall health in elementary students.
Several clients who have recently come to the local health clinic in a rural county are diagnosed with tuberculosis (TB). After reporting the occurrence to the health department, which community focused action should the nurse implement first?
- A. Collaborate with local schools in screening children.
- B. Develop a community educational program.
- C. Provide referrals for home health care follow up.
- D. Perform a community health assessment.
Correct Answer: D
Rationale: A community health assessment is the first step to understand the extent of the TB outbreak, identify high-risk groups, and tailor interventions like screening or education effectively.
The school nurse administers methylphenidate to an adolescent with Attention Deficit Hyperactivity Disorder (ADHD). When evaluating the drug's effectiveness, which information is most important for the nurse to review?
- A. Parent's report about behavior.
- B. Current grade report.
- C. Self-report about treatment progress.
- D. Past grade report.
Correct Answer: A
Rationale: Parents' reports on behavior provide critical insights into ADHD symptom management across settings, essential for evaluating methylphenidate's effectiveness.
A middle-aged client presents for an annual health visit at a community clinic. The client is 5 feet 10 inches (177.8 cm) tall, weighs 250 pounds (113.4 kg), and works as an accountant. The client has smoked at least one pack of cigarettes every day for the last 15 years. Which secondary prevention measure should the nurse recommend the client to follow?
- A. Smoking cessation.
- B. Compliance with antihypertensive and lipid lowering agents.
- C. Blood pressure and lipid screening.
- D. Increase physical activity and diet low in saturated fat.
Correct Answer: C
Rationale: Blood pressure and lipid screening are secondary prevention measures to detect cardiovascular issues early, critical for a smoker with obesity and high cardiovascular risk.